Variations in the pathophysiology of respiratory syncytial virus infection depend on the age at onset.

BACKGROUND: Lower respiratory tract infections due to respiratory syncytial virus are associated with morbidity and mortality in infants and children. Thus precise elucidation of respiratory syncytial virus lower respiratory tract infection pathophysiology is important. METHODS: Medical records of hospitalized patients were reviewed. Patients were divided into three groups. Group I: patients who improved without oxygen supply. Group II: patients who received oxygen supply, but not nasal high-flow cannula therapy. Group III: patients who received nasal high-flow cannula. Patients were also divided by age group into the <6 months and ≥6 months groups. Parameters for differentiating the severity among groups were then evaluated. Further, serum concentration of high-mobility group box-1 and several cytokines (Inerleukin-6, soluble tumor necrosis factor receptor-1/2, Interleukin-18, Interferon-gamma responsive protein-100) were evaluated. RESULTS: One hundred eighty-nine were enrolled. An analysis of variance for those <6 months showed overall differences including younger age, lower pH, and increased partial pressure of carbon dioxide (pCO2), bicarbonate (HCO3-), and base excess at the time of admission. On the other hand, analysis of variance for ≥6 months revealed that, in addition to a lower pH and increased pCO2, patients showed differences including decreased serum total protein and albumin, and increased aspartate aminotransferase (AST), alanin aminotransferase (ALT), lactate dehydrogenase (LDH), Ferritin and C-reactive protein (CRP) levels. Further, evaluation of serum cytokines showed that IL-6, s tumor necrotizing factor receptor-1/2, and high-mobility group box-1 were higher in Group II/III among the ≥6 months age group, but not for those in the <6 months group. CONCLUSIONS: The pathophysiology of severe respiratory syncytial virus lower respiratory tract infection varies according to the age at onset. In late infancy and childhood, a certain proportion of patients show a hyperinflammatory status.

A case of congenital herpes simplex virus infection diagnosed at 8 months of age.

We present the case of an 8-month-old boy with the repeated recurrence of vesicles from the time of birth and who subsequently manifested psychomotor developmental delay. We retrospectively diagnosed the patient with congenital herpes simplex virus (HSV) infection. Computed tomography showed multiple calcifications in the periventricular white matter and thalami. The bilateral deep white matter showed an abnormally high signal intensity on T2-weighted magnetic resonance imaging. The patient required consecutive, suppressive therapy with valacyclovir to prevent the repeated recurrence of vesicles. This case presented a milder phenotype of congenital HSV infection in comparison to previous reports, and highlights the importance of the careful examination for this disease when neonates present with skin lesions.

Non-invasive discrimination of acute focal bacterial nephritis with pyelonephritis.

BACKGROUND: The appropriate antimicrobial treatment period for febrile urinary tract infection (UTI) can be changed, depending on whether the patient has acute focal bacterial nephritis (AFBN). The aim of this study was to clarify the characteristics of AFBN compared with those of acute pyelonephritis (APN) and establish a strategy to detect AFBN. METHODS: A total of 77 patients diagnosed with febrile UTI were enrolled. They were divided into APN (n = 64) and AFBN groups (n = 13). The clinical data and other laboratory biomarkers were retrospectively analyzed. RESULTS: The time required for fever resolution after antimicrobial treatment was significantly longer in the AFBN group than in the APN group (2.77 days vs 1.11 days, respectively, P < 0.001). Also, the time to disappearance of pyuria after antimicrobial treatment was longer in the AFBN group than in the APN group (6.22 days vs 2.32 days, respectively, P = 0.001). Fever lasting >1.75 days after antimicrobial treatment had a sensitivity of 92% and specificity of 79% for the detection of AFBN, while pyuria disappearance after 4 days had a sensitivity of 88% and specificity of 85%. When patients fulfilled both cut-offs, the sensitivity and specificity were 89% and 97%. CONCLUSION: Acute focal bacterial nephritis was associated with fever of significantly longer duration after antimicrobial treatment, and it took a longer time for pyuria to disappear. Children with febrile UTI should be evaluated for AFBN if the fever persists ≥48 h after the initiation of antimicrobial treatment and if pyuria lasts for 4 days.

Serial sonographic findings during progression from acute pyelonephritis to renal abscess: a rare case report.

Renal abscess, accumulation of infective fluid in the kidney, is a rare pathology. Currently, no reports of the serial imaging changes of acute pyelonephritis (APN) progressing to renal abscess exist. We report clinical and serial sonographic findings of a patient with hyper-immunoglobulin E syndrome, a primary immunodeficiency, who developed APN that progressed to renal abscess. Renal ultrasonography revealed that echogenicity of infectious lesions dramatically changed from isoechoic to hyperechoic and to hypoechoic during progression. These findings are useful for differential diagnosis of APN, acute focal bacterial nephritis, and renal abscess.

Construction of a scoring system for predicting the risk of severe gastrointestinal involvement in Henoch-Schönlein Purpura.

OBJECTIVE: To evaluate the parameters associated with significant gastrointestinal (GI) involvement in Henoch-Schönlein Purpura (HSP), and construct a scoring system for the identification of patients at high risk of gross blood in stools. STUDY DESIGN: Data for HSP patients hospitalized at each of seven institutes were retrospectively analyzed. Patients were divided into four groups according to the consequent severity of GI involvement. Identification of laboratory parameters at the time of admission were then used to differentiate the groups, and a scoring system to predict gross intestinal bleeding was constructed. Prognostic efficiency, correlation with the subsequent duration of abdominal pain, and association with manifestations excluding abdominal pain were also analyzed. RESULTS: An analysis of variance (ANOVA) test showed significant intergroup differences in white blood cell (WBC) count, neutrophil count, serum albumin, potassium, plasma D-dimer and coagulation factor XIII activity. A scoring system consisting of these parameters showed a good prognostic value for gross intestinal bleeding in a receiver operating characteristic (ROC) analysis, and a cut-off value of 4 points showed a sensitivity of 90.0% and specificity of 80.6%. The score was also correlated with the duration of abdominal pain after admission. A significantly higher score (s) was observed in patients presenting with nephritis, although the predictive value was poor. CONCLUSION: A scoring system consisting of generally available parameters was of use in predicting severe GI involvement in HSP patients. Although further study is needed, initial therapy in accordance with disease activity may be taken into consideration using this scoring system.

[Care continuity for children with psychosomatic disorders].

According to the analysis in pediatrics, 5.8% of children aged equal or more than 3 years attended pediatric outpatient clinics had psychosomatic problems. The logistic regression analysis demonstrated that children with psychosomatic problems had complained more chronic fatigue (odds ratio: 2.55), headache (2.42) and recurrent abdominal pain(2.03) in comparison with controls. The other study showed many children with school phobia had trouble with class mates and complained somatoform disorders. Working with somatizing patients and their parents can be frustrating the pediatrician, and comorbid psychiatric disorders are common in these patients. To get good carryover, the psychiatric consult is needed if they have suffered from major depressive disorder, and other anxiety disorders.

A randomized, double-blind, placebo-controlled study of atomoxetine in Japanese children and adolescents with attention-deficit/hyperactivity disorder.

OBJECTIVES: Until the recent approval of methylphenidate (MPH), Japan had no approved treatment for attention-deficit/hyperactivity disorder (ADHD). The need still exists for an effective, safe, nonstimulant treatment. This first placebo-controlled Japan study of an ADHD nonstimulant therapy assessed atomoxetine efficacy and safety to determine the optimal dose for controlling ADHD symptoms in children and adolescents. METHODS: A total of 245 Japanese children and adolescents, aged 6-17 years and diagnosed with ADHD, were randomly assigned to receive placebo or one of three atomoxetine doses (0.5, 1.2, and 1.8 mg/kg per day) over 8 weeks. Symptoms were assessed with the Japanese Attention-Deficit/Hyperactivity Disorder Rating Scale-IV-Parent Version: Investigator scored and integrated with teacher reports (ADHD RS-IV-J:I/Sch). Adverse events, vital signs, laboratory tests, and electrocardiograms (ECGs) were obtained for safety analysis. RESULTS: In all, 234 patients completed the study. Atomoxetine at 1.8 mg/kg per day was significantly superior to placebo in reducing ADHD symptoms (p = 0.01; one-sided). Decreased appetite and vomiting were significantly greater in the atomoxetine treatment groups; however, no clinically significant differences were observed. Two patients discontinued due to affect lability and headache. A linear dose-response and vital signs similar to those from other atomoxetine studies were observed. CONCLUSION: Atomoxetine provides an effective and safe nonstimulant option for the treatment of Japanese pediatric patients with ADHD.

Human milk reduces the risk of retinal detachment in extremely low-birthweight infants.

BACKGROUND: Retinopathy of prematurity (ROP) is a major cause of blindness in children. Because the use of oxygen is a known risk factor for development of ROP, supplemental oxygen is used carefully. However, it does not necessarily reduce the morbidity of ROP-induced blindness. The aim of the present study was to identify the possible risk factors for progression to retinal detachment, a most relevant cause of visual impairment, in extremely low-birthweight infants (ELBWI). METHODS: The medical records of the 42 ELBWI who were admitted to the neonatal intensive care unit in Asahikawa Kosei Hospital from April 1999 to March 2004 were retrospectively reviewed. Seven infants (16.7% of the ELBWI) developed retinal detachment and two of them became blind. Perinatal and postnatal variables in these infants with retinal detachment were compared with those in infants without retinal detachment. RESULTS: A striking difference in the daily intake of human milk was found between the infants with or without retinal detachment when their gestational ages at birth were matched. The infants without retinal detachment were fed more human milk (67-83% volume of total nutritional intake) as compared to those with retinal detachment (24-38% volume of total nutritional intake) at a specific postnatal period, 5-7 weeks postnatal age. CONCLUSIONS: Human milk may contain some beneficial factors to reduce the severity of ROP. Identifying these factors in human milk may contribute to development of a strategy to rescue premature infants from blindness.

[Usefulness of growth chart in children and adolescents with chronic fatigue syndrome].

We presented three sheets of growth chart in children with chronic fatigue syndrome. The growth chart in 14-year-old boy (patient 1) showed decreased weight gain because of too much exercise. After that he complained nausea, abdominal pain, sleep disturbance and debilitating fatigue. The growth chart in 12-year-old girl (patient 2) revealed increased weight gain because of overeating due to the divorce of her parents. She developed syncope, sleep disturbance, and fatigue during overeating. The growth chart in 13-year-old girl (patient 3) showed decreased weight gain after she developed lymph node enlargement. We diagnosed her as autoimmune fatigue syndrome because of persistent positive antinuclear antibody. Although growth chart will not be able to detect childhood chronic fatigue syndrome prospectively, the chart may be useful for detecting some life events in these children.

Research on promotion of management of children with psychosomatic and psychosocial disorders in Japan.

BACKGROUND: The number of children with psychosomatic and psychosocial disorders has been increasing in Japan. There are, however, few trained pediatricians who have adequate knowledge of the treatment needed. The Research Group on the Promotion of Management of Children with Psychosomatic and Psychosocial Disorders carried out the present study to (i) disseminate knowledge about psychosomatic and psychosocial disorders of children; and (ii) establish a community-based network model to ensure effective communication among relevant institutions. METHODS: To disseminate knowledge of the psychosocial and psychosomatic disorders, the Research Group compiled the Handbook for Psychosomatic Disorders of Children and distributed it to pediatricians throughout Japan. A follow-up questionnaire survey was then carried out. Also, in order to examine the current status of the communication network between pediatricians and the related institutions, the Research Group conducted a questionnaire survey on general pediatricians. RESULTS: Sixty-five percent of the respondents indicated that they were actually using the Handbook. The topics in the Handbook that were most frequently referred to by the respondents were attention deficit hyperactivity disorders, school refusal, eating disorders, and orthostatic dysregulation. Thirty-seven percent of the participants indicated changes in their behavior towards psychosomatic and psychosocial problems. The results of the survey on communication networks found that the pediatricians generally collaborated with different institutions depending on the nature of the problems, such as school refusal and bullying, developmental disorders, child abuse and maltreatment, and others. CONCLUSION: Promotion of the Handbook would greatly contribute to improving the management of children with psychosomatic and psychosocial disorders, together with the construction of the basic network model for management of these children.

Computerized version of the Wisconsin card sorting test in children with high-functioning autistic disorder or attention-deficit/hyperactivity disorder.

To determine executive dysfunctions in children with autistic disorder or attention-deficit/hyperactivity disorder (ADHD), we investigated high-functioning autistic (full scale IQ score >or==70), ADHD, and control children using the computerized version of the Wisconsin Card Sorting Test. Data were obtained from 17 autistic children (16 boys and 1 girl, mean age+/-SD: 12.5+/-4.3), 22 ADHD children (20 boys and 2 girls, mean age+/-SD 11.3+/-2.6), and 25 control children (13 boys and 12 girls, mean age+/-SD: 12.7+/-3.1). Performances, indicated by mean number of categories achieved (5.4 in autistic, 6.5 in ADHD, and 8.8 in control group), total errors (38.2, 38.4, and 25.6, respectively), perseverative errors (11.4, 13.5, and 5.7), nonperseverative errors (27.1, 25.0, and 19.9), and Nelson type perseverative errors (8.9, 8.4, and 2.3), were significantly poorer in both autistic and ADHD groups than control group (P<0.01). Comparing the autistic group to the ADHD group, there were no significant differences in age, gender, scores of full-scale intelligent quotient (IQ), verbal or performance IQ, number of categories achieved or errors. The ADHD group, however, showed more frequent Milner type perseverative errors than the autistic group (P<0.05). The present study suggests that some kinds of executive function are more impaired in children with ADHD than in those with high-functioning autism, and that Milner type perseverative errors is useful parameter to differentiate the executive dysfunctions between autistic and ADHD children.